Special Situations and Problems
FAILURE TO RESPOND TO SCLEROTHERAPY
Failure of sclerotherapy (defined as failure to eliminate the vessels being treated, or immediate recurrence) usually results from an incorrect diagnosis and treatment plan, failure of medication delivery, or noncompliance with recommended compression. Table 18-1 outlines the measures to ponder when a patient does not respond to sclerotherapy.
TABLE 18-1
When Patients Do Not Respond to Sclerotherapy
• Was Doppler examination adequate?
• Is a Duplex examination required or need to be done again?
• Reticular vein adequately treated?
• Compliance with compression?
• Change the solution type?
• Was patient on hormonal therapy (HRT or BCP)?
• Change in patient’s medical status?
Diagnosis and Treatment Plan
In the majority of cases, it is found that some high-pressure source of reflux was not adequately addressed prior to sclerosis of terminal varices. After a treatment failure, Duplex ultrasound evaluation should be performed to ensure that the pattern of reflux is fully understood. Although Chapter 7 includes a case study of treatment failure successfully corrected by Doppler-guided sclerotherapy. Today, Duplex ultrasound examination has largely replaced Doppler evaluation. If junctional incompetence is at the root of treatment failure, endovenous ablation of the reflux is indicated before proceeding to secondary sclerotherapy or local phlebectomy. Prolonged pigmentation following sclerotherapy may also be due to continued hydrostatic pressure from a proximal source and should be investigated by Duplex ultrasound.
Sclerosant
In some cases of treatment failure, it is found that the concentration and volume of the sclerosant used were insufficient to overcome dilution by blood flowing in the treated vessel, especially when using liquid sclerosant as opposed to foam. Switching from liquid to foam sclerosant can be a successful method of getting veins larger than 2 mm to respond if they have had a poor response to liquid. If a vessel is too large to be treated using the maximum recommended doses of available sclerosants and/or foamed sclerosants, combinations of more than one sclerosant may be used in sequence. Some patients are resistant to one category of sclerosing solution, yet when switched to another, i.e., from detergent to hyperosmolar, they respond well. Surgical removal by phlebectomy offers an excellent alternative for vessels that are resistant to chemical ablation. Radiofrequency or laser endovenous ablation of the saphenofemoral junction (SFJ) is the preferred and more effective alternative to sclerotherapy of the SFJ in the United States in 2011.
Compression
If the amount of compression used (or patient compliance with compression) is insufficient to adequately compress a large vessel, a large thrombus will form and likely will later recanalize. Drainage of the coagula from this thrombus followed by compression will help it sclerose (Chapter 24). Compression stockings provide dependable compression and the use of two pairs of stockings for additive compression can sometimes be helpful. The two-pair-stocking method is particularly useful when a patient complains that they cannot pull a single stocking beyond the ankles. Patients who complain that they cannot be “confined” by a support hose often remove compression after a few days and would be considered noncompliant. A vessel that cannot be adequately compressed is not a good candidate for treatment by primary sclerotherapy. Surgical removal and endovenous ablation by means of a radiofrequency or laser device offers a good alternative for these cases.
VARICEAL HEMORRHAGE
Variceal hemorrhage is more common than usually realized; patients with variceal hemorrhage often complain of waking up in a pool of blood. Rarely, blood loss from a leg varix can result in death. The bleeding vessel can be surprisingly small, as seen in Chapter 4 (Figure 4-7). Patients with variceal hemorrhage usually present to an emergency department, where the traditional management has been to oversew the involved vessel. In our practice, sclerotherapy has been successfully performed on an urgent basis to immediately close the bleeding site even without eliminating reflux from above. Foamed detergent sclerosant is particularly effective in this situation. Many of these patients have very advanced disease or are in such poor health that only palliative therapy can be offered.
Oversewing
Oversewing a vessel gives short-term control, but without further treatment, hemorrhage will usually recur. Correct treatment requires ablation or removal of the dilated superficial thin-walled vessel that has ruptured, together with correction of the major source of reflux feeding the ruptured vessel. Ongoing use of compression therapy is very helpful.
Definitive Treatment
Variceal hemorrhage can easily be treated by primary sclerotherapy or by primary phlebectomy, as described in the chapters devoted to those procedures. Vessels that have dilated to the point of rupture have lost their ability to contract in spasm, and if treatment is by sclerotherapy, the solution (sclerosant) spread must extend far enough to reach vessels proximal to the bleeding point. These vessels will then contract in spasm, thus reducing flow to the site. Ambulatory phlebectomy may be employed to avulse vessels leading to the bleeding site as the variceal hemorrhage point is shred with the phlebectomy hook.
COMBINED DEEP AND SUPERFICIAL REFLUX
When patients with superficial varices are also found to have deep venous system reflux, a complete normalization of venous flow will be impossible. In many cases, the superficial component of reflux may be an insignificant part of the overall disease process, no matter how impressive the superficial varices. One cannot assume that treating the superficial varicosities will make no difference, however. Evidence indicates that even when deep venous reflux exists, treatment of the superficial reflux contributes to significant clinical improvement, although in some cases, the SEPS (subfascial endoscopic perforator surgery) procedure may also be necessary.1–3 This has been our experience as well. Even with the presence of significant deep venous system reflux, treating superficial refluxing varicosities can significantly improve clinical symptoms such as ulceration. Treatment of superficial refluxing vessels may therefore be indicated not only for cosmetic reasons, but also if there is evidence that a significant reduction in total reflux volume can be achieved. These patients need frequent (up to quarterly) follow-up and will often need subsequent treatment by foam sclerotherapy to close perforating veins that develop reflux due to deep venous system pressure. The advent of foam sclerotherapy is likely to reduce the need for the SEPS procedure.
Informed Consent
A patient with significant deep venous system reflux must understand and accept the possibility that symptoms may not be cured nor significantly ameliorated by sclerosis of superficial veins. It is helpful to address this issue in an informed consent document.
Superficial Veins as a Major Reflux Pathway
If the venous refilling time (VRT) can be improved in any degree by the occlusion of superficial vessels, then ablation of superficial incompetent vessels by sclerotherapy will certainly improve overall venous function and will probably ameliorate the symptoms. If the VRT cannot be improved by occluding superficial vessels, but superficial disease is so extensive that in the clinician’s judgment it is believed responsible for a significant fraction of the overall impairment of venous function, then ablation of superficial incompetent vessels by sclerotherapy may improve overall venous function but may or may not ameliorate the symptoms.
Superficial Veins as a Minor Reflux Pathway
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